CBT for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common functional gastrointestinal syndrome characterized by abdominal pain and bowel disturbances (diarrhea and/or constipation).  It is estimated to affect 10 to 20% of the population and treatment approaches are often unsatisfactory. 

Irritable bowel syndrome can be viewed as a neuroscience problem from several perspectives.  Abnormal gastrointestinal motility and hypersensitivity has been identified in IBS--these functions are related to gut nervous system function.  The rates of depression and anxiety are high in IBS populations.  Pain perception is a central nervous system function.  Psychotropic medications appear to be helpful in controlling IBS symptoms in some patients.

An additional neuroscience perspective is the evolving evidence for cognitive behavioral therapy to reduction distress and suffering in IBS.  Moss-Morris and colleagues from the UK and New Zealand recently demonstrated the effectiveness of a CBT-self management program for IBS in primary care.

A series of sixty-four primary care patients were randomized to manualized CBT or a treatment as usual control condition.  The CBT group completed a seven week program using a manual, one sixty minute face-to-face therapy session and two sixty minute telephone sessions.

The key elements of the CBT program for IBS in primary care included:
1. IBS education--autonomic nervous system interacts with gut, interaction between thoughts, feelings and behaviour and how these can impact stress levels and GI symptoms
2. Assess symptoms and self-monitoring--daily diary of IBS symptoms linked to stress and eating behaviors
3. Managing IBS symptoms--behavioral management of diarrhea or constipation, set goals for managing symptoms
4. Managing unhelpful thoughts-introduction to concept of negative automatic thoughts and their relationship to IBS
5. Personal expectations and activity patterns--perfectionism and other unhelpful personal expectations reviewed
6. Relaxation and stress management-basis stress management and sleep hygiene review--relaxation CD provided
7. Managing flare-ups and the future--probability of flare-ups reviewed, skill use to manage flare-ups and ongoing symptoms emphasized

The key outcome findings for the study:
Symptom relief across all three assessment periods (77% for CBT vs 21% of controls)
At 8 months the CBT group had superior ratings on an IBS symptom severity measure (83% vs 49% of control with clinically significant change)

The authors note that CBT was well accepted with good adherence to treatment.  A majority of subjects felt CBT was more effective than any previous treatment they had received.  The model is relatively inexpensive compared to a standard 12 to 16 week individual CBT therapy course offered by a psychotherapist.

There is need for identifying ways to incorporate this type of model in the U.S.  Adoption of cost-effective treatments is important in this common, chronic disorder associated with significant distress and health care utilization.

Photo of young dik dik from Sudan courtesy of Sarah Yates

Moss-Morris R, McAlpine L, Didsbury LP, & Spence MJ (2010). A randomized controlled trial of a cognitive behavioural therapy-based self-management intervention for irritable bowel syndrome in primary care. Psychological medicine, 40 (1), 85-94 PMID: 19531276